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CVS Caremark is required by law 2026

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The document is a prior authorization request form for the medication Xolair, administered by CVS Caremark. It outlines the necessary information and steps required for healthcare providers to obtain approval for coverage of Xolair for patients with conditions such as allergic asthma or chronic idiopathic urticaria. The form includes sections for patient demographics, diagnosis, treatment history, and specific criteria that must be met for authorization. Additionally, it provides contact information for inquiries and options for recipients to opt-out of telemarketing faxes.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, date, ID, and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
Fill in the physician's details including name, specialty, NPI number, and contact information. If applicable, provide referring and rendering provider information.
Complete the required demographic information such as patient weight and height. This data is essential for determining eligibility.
Indicate the place of service for the requested drug by selecting one of the options provided.
Answer the criteria questions regarding diagnosis and treatment history. Be thorough to ensure all necessary information is captured.
Finally, review all entries for accuracy before signing at the bottom of the form. Once completed, fax it to CVS Caremark using the provided number.

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